Form ORR R-317 Page 1 ORR R-317 Page 1 Authorization for Release of Information/English Page 1

US Department of Health and Human Services Authorization for Release of Information

OFFICE OF REFUGEE RESETTLEMENT

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization, then sign and date it in black ink.

I Authorize any investigator, special agent, or other duly accredited representative of the Office of Refugee Resettlement conducting my background investigation, to obtain any information about me from U.S. criminal justice and immigration agencies, or other sources of information. This information may include, but is not limited to, my national and state criminal history and my immigration record.

I Authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of the Office of Refugee Resettlement regardless of any previous agreement to the contrary.

I Understand that the information released by any custodian of my records and any other sources of information about me is for official use by the U.S. Government for the purposes stated above, and may be disclosed by the U.S. Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original. This authorization is valid for one (1) year from the date signed.

Signature (Sign in ink)	Full Name (Type or Print Legibly)			Date Signed
Other names used (AKA)	Sponsor’s DOB			Social Security Number (optional)*
Current Address		State	ZIP Code	Home Telephone Number (Include Area Code) ( )

^*The provision of the Social Security Number is not mandatory. However, if not provided, ORR may be unable to complete the background check necessary for the reunification procedure.

CARE PROVIDER / CASE MANAGER/ DIGITAL SITE USE:

UAC NAME: _________________________________________ UAC A#: _________________________________________

FACILITY NAME: __________________________ DIGITAL SITE LOCATION (IF ANY) _________________________

Authorization for Release of Information, Rev. 3/21/05, Rev. 03.16.06

ORR R-317

[OMB 0970-0278, valid through 06/30/2008]

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